Detox Intake Form
Detox Health Intake Form
Your time, thoughtfulness, and honesty are greatly appreciated.
Thank-you for your interest in this detox & wellness retreat. Please complete this form, even if you have submitted one for previous programs. The nature of your responses to the following questions will go a long way in assisting my understanding of your life & health, and will help me tailor the week to your specific needs.
Please read the forms carefully, sign, and return them as soon as possible by:
Mail:
Omega Institute for Holistic Studies
Attn: Registration Dept
150 Lake Drive
Rhinebeck, NY 12572
Or scan and email:
classapplications@
Please note that because our cleansing program is educational & experiential in nature, it is not intended as therapy for serious illness, nor a substitution for primary medical care.
Also, If you consume caffeine, nicotine, and/or artificial sweeteners regularly, I highly recommend that you reduce and/or wean yourself off them the week before you come, if possible.
GENERAL INFORMATION
Name:____________________________________________________________
Address:___________________________________________________________
City:_____________________________________ State:______________Zip:___________________
Phone: Home:______________________Cell: ___________________________
Email Address:______________________________________________________
Occupation________________________________________
Hours per week_________ Retired_____________________
Height____________ Weight__________________________
Has any other family member already been a patient?____________________
or attended a workshop of Dr. Tom? _______________________________
___Married___Partnership____Separated___Divorced____Widowed___Single
Live with:___Spouse___Partner___Parents ___Children ___Friends ____Alone
Do you have any children? Yes No How many? ________
Have you ever consulted with a Naturopathic Physician before? Yes No
What is the primary reason for your interest in this retreat?
______________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________
What would you like to accomplish with this program?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are your most important health concerns at this time?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How did these issues/conditions develop?
Are there any traumatic events that you can identify as having caused or clearly aggravated your health challenges? What happened in your life around this time? Do you know anything about your birth process? If you prefer, list these in order of occurrence on a separate page
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________
Please list any prescriptions, medications, and supplements which you are presently taking and why?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever undertaken a cleanse before? _____yes _____no
If yes, for how long?_________________________________________________
Are you having regular bowel movements? _____yes ______ no
How many per day?_________ Well formed? _______________________
Easily eliminated? __________________________________________________
How would you rate your energy level? excellent good mediocre poor
How is your sleep? fall asleep easily? stay asleep throughout night? wake feeling refreshed?__________________________________________________________________
How would you rate your mood? ___excellent ___good ____average____poor
How would you rate your pain level? 0 (none) to 10 (extreme)_____________
DIET:
How is your appetite? ____extreme ____strong ____good ___lacking
What do you crave? _____carbs ____sugar _____salt _____meat ____ choc
other?________________________________________________________
How many meals do you generally eat each day? ___1 ___2 ____3 ____3+
Do you: ___eat out often ___diet frequently ___skip meals frequently
Do you have any special diet or eating restrictions? ____Yes ___No
if yes, please explain________________________________________________
List the primary foods you include in your diet
__________________________________________________________________
List the foods you exclude from your diet at this time______________________________________________________________
Do you have any food sensitivities that you are aware of? ______no _____yes
If yes, what foods?___________________________________________________
Do you currently experience food binges? ______no ______yes
If yes, what are the trigger foods?______________________________________
Are you currently using coffee, diet sodas, or nicotine? _____no ______ yes
If yes, how much daily?__________________________________________________________________
Mark those that you consume regularly:
____Caffeinated teas ___Artificial sweeteners ____Processed foods ____Preservatives ___Refined foods ____Margarine
___Trans-fatty acids ___Sugar/sweets
PAST MEDICAL HISTORY
YOUR PRENATAL/BIRTH PROCESS:
Any known problems/birth trauma during your mother’s pregnancy with you:_______________________________________________________________
C-section?________ Umbilical cord problems?_______forceps used?_______ Antibiotics?________ Breast fed?________ how long?______ Formula (kind):________________________how long?_______
Age solid foods began:_________
What foods were eaten in your first year of life___________________________
PERSONAL:
Major accidents/traumas (with dates):__________________________________
Severe stresses/emotional traumas:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are you happy in your job or career? ____Yes ____No __________________________________________________________________
What personal goals do you have?________________________________________________________________________________________________________________________________
What makes you happy?_______________________________________________________________________________________________________________________________
What are you grateful for?___________________________________________
What is your individual & unique purpose in this life?_________________________________________________________________________________________________________________________________
What would you like to change most about your life?_________________________________________________________________________________________________________________________________
What behaviors, habits, or thoughts would you like to eliminate?____________________________________________________________________________________________________________________________
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